[Development of Deep Venous Thrombosis Shortly after Neurological Surgery].

Little is known about the incidence and characteristics of deep venous thrombosis(DVT)developing shortly after neurological surgery. Lower extremity venous ultrasound scanning was performed before and after surgery, and retrospective data of 157 surgical cases, including endovascular surgery(42.0%), craniotomy(28.7%), burr hole(24.2%), and shunt(3.2%), were evaluated. DVT that had not been pre-operatively observed was discovered in five cases of surgery(five patients, 3.2%)on the day following the surgery, and it was asymptomatic in all cases. One patient was diagnosed with pulmonary thromboembolism as a complication. No difference in characteristic factors was observed between the presence and absence of DVT development. In addition, DVT was detected on preoperative examinations in 10 cases of surgery(10 patients, 6.4%). On the basis of these results, ambulation on the first postoperative day is considered mostly safe. On the other hand, taking into account the increase in the number of patients with DVT and the possibility that a thrombus present in calf veins propagates toward the proximal side, pre-and post-operative screening tests should be performed more often.

Efficacy of Upper Extremity Robotic Therapy in Subacute Poststroke Hemiplegia: An Exploratory Randomized Trial.

BACKGROUND AND PURPOSE: Our aim was to study the efficacy of robotic therapy as an adjuvant to standard therapy during poststroke rehabilitation. METHODS: Prospective, open, blinded end point, randomized, multicenter exploratory clinical trial in Japan of 60 individuals with mild to moderate hemiplegia 4 to 8 weeks post stroke randomized to receive standard therapy plus 40 minutes of either robotic or self-guided therapy for 6 weeks (7 days/week). Upper extremity impairment before and after intervention was measured using the Fugl-Meyer assessment, Wolf Motor Function Test, and Motor Activity Log. RESULTS: Robotic therapy significantly improved Fugl-Meyer assessment flexor synergy (2.1±2.7 versus -0.1±2.4; P<0.01) and proximal upper extremity (4.8±5.0 versus 1.9±5.5; P<0.05) compared with self-guided therapy. No significant changes in Wolf Motor Function Test or Motor Activity Log were observed. Robotic therapy also significantly improved Fugl-Meyer assessment proximal upper extremity among low-functioning patients (baseline Fugl-Meyer assessment score <30) and among patients with Wolf Motor Function Test ≥120 at baseline compared with self-guided therapy (P<0.05 for both). CONCLUSIONS: Robotic therapy as an adjuvant to standard rehabilitation may improve upper extremity recovery in moderately impaired poststroke patients. Results of this exploratory study should be interpreted with caution. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/. Unique identifier: UMIN000001619.

Correlation of motor function with transcallosal and intracortical inhibition after stroke.

OBJECTIVE: The inhibitory role of neuronal networks in motor recovery after stroke remains to be elucidated. We examined the influence of transcallosal inhibition and short intracortical inhibition on motor recovery after stroke. We also investigated the correlation between transcallosal inhibition and mirror activity. DESIGN: A cross-sectional study. SUBJECTS: Thirty-eight chronic stroke patients. METHODS: Transcallosal inhibition was evaluated using single transcranial magnetic stimulation, and short intracortical inhibition was assessed using paired-pulse transcranial magnetic stimulation. Mirror activity was measured during tonic contraction of the contralateral hand. RESULTS: Transcallosal inhibition from the contralesional to the ipsilesional motor cortex correlated positively with motor function of the paretic hand; in contrast, transcallosal inhibition to the ipsilesional motor cortex correlated negatively with mirror activity of the paretic hand in both cortical and subcortical stroke patients. Short intracortical inhibition of the ipsilesional motor cortex correlated negatively with motor function of the paretic hand in only the subcortical stroke patients. CONCLUSION: Transcallosal inhibition from the contralesional to the ipsilesional motor cortex may inhibit mirror movements in stroke patients with good motor function. The weak transcallosal inhibition in patients after stroke with poor motor function may be ineffective for inhibiting mirror movement; however, it may have the advantage of facilitating motor recovery.

Repetitive transcranial magnetic stimulation over bilateral hemispheres enhances motor function and training effect of paretic hand in patients after stroke.

OBJECTIVE: The interhemispheric competition model proposes that the functional recovery of motor deficits in patients after stroke can be achieved by increasing the excitability of the affected hemisphere or decreasing the excitability of the unaffected hemisphere. We investigated whether bilateral repetitive transcranial magnetic stimulation might improve the paretic hand in patients after stroke. DESIGN: A double-blind study. PATIENTS: Thirty patients with chronic subcortical stroke. METHODS: The patients were randomly assigned to receive 1 Hz repetitive transcranial magnetic stimulation over the unaffected hemisphere, 10 Hz repetitive transcranial magnetic stimulation over the affected hemisphere, or bilateral repetitive transcranial magnetic stimulation comprising both the 1 Hz and 10 Hz repetitive transcranial magnetic stimulation. All patients underwent motor training following repetitive transcranial magnetic stimulation. RESULTS: Bilateral repetitive transcranial magnetic stimulation and 1 Hz repetitive transcranial magnetic stimulation immediately improved acceleration in the paretic hand. Compared with 1 Hz repetitive transcranial magnetic stimulation, bilateral repetitive transcranial magnetic stimulation decreased the inhibitory function of the affected motor cortex and enhanced the effect of motor training on pinch force. Moreover, this effect of motor training lasted for one week. On the other hand, 10 Hz repetitive transcranial magnetic stimulation had no effect on the motor function. CONCLUSION: Bilateral repetitive transcranial magnetic stimulation improved the motor training effect on the paretic hand of patients after stroke more than unilateral stimulation in pinch force; this might indicate a new neurorehabilitative strategy for stroke.

Inhibition of the unaffected motor cortex by 1 Hz repetitive transcranical magnetic stimulation enhances motor performance and training effect of the paretic hand in patients with chronic stroke.

OBJECTIVE: Recent reports demonstrated that low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere improved the affected hand function in chronic stroke patients. We investigated whether 1 Hz rTMS improved the motor learning of the affected hand in patients after stroke. DESIGN: A double-blind study. PATIENTS: Twenty patients with chronic subcortical stroke. METHODS: The patients were randomly assigned to receive either a sub-threshold rTMS over the unaffected hemisphere (1 Hz, 25 minutes) or sham stimulation, and all patients performed a pinching task after stimulation. We evaluated the motor function of the affected hand and the excitatory and inhibitory function of the affected motor cortex by transcranial magnetic stimulation. RESULTS: Compared with sham stimulation, rTMS induced an increase in the excitability of the affected motor cortex(p < 0.001) and an improvement in acceleration of the affected hand (p = 0.006). Moreover, the effect of motor training on pinch force was enhanced by rTMS (p < 0.001). These improvement in the motor function lasted for one week after rTMS and motor training (p < 0.001). CONCLUSION: rTMS improved the motor learning of the affected hand in patients after stroke; thus, it can apply as anew rehabilitation strategy for patients after stroke.

Repetitive transcranial magnetic stimulation of the unaffected hemisphere in a patient who was forced to use the affected hand.

We present a case report of a 56-yr-old chronic stroke patient with right hemiparesis who was treated with repetitive transcranial magnetic stimulation (rTMS) therapy. Before stroke, the patient had suffered an accident that led to paralysis and contracture of the left upper limb, and, subsequently, he was forced to use only his right upper limb for routine activities, despite right hemiparesis. We performed subthreshold rTMS (1 Hz, 25 mins) and sham stimulation of the contralesional primary motor cortex (M1) at different times. Immediately after rTMS, the patient was able to write characters with increased speed and accuracy, and this effect continued for more than 7 days; however, this was not the case after sham stimulation. Moreover, the writing practice after rTMS improved the patient's pinch force.